Skip to Content

Provider Manual

Risk Adjustment - Kidney disease

Last Updated on January 24, 2019

Hierarchical Condition Category Coding and Kidney Disease

The Center for Medicare and Medicaid Services (CMS) has associated approximately 60 International Classification of Diseases-10 (ICD-10) codes related to a patient’s renal status to identify 5 Hierarchical Condition Category (HCC) codes.  The 5 HCC codes associated with renal status are:

  • HCC 134 – Dependence on Renal Dialysis
  • HCC 135 – Acute Renal Failure
  • HCC 136 – Chronic Kidney Disease (Stage 5)
  • HCC 137 – Chronic Kidney Disease, Severe (Stage 4)
  • HCC 138 – Chronic Kidney Disease, Moderate (Stage 3)

 The following factors will determine whether a patient’s renal status meets criteria to assign an ICD-10 code that links to a HCC code:

  • Is the condition chronic? – Risk factor scores (which affect payment) assigned to conditions are different, based upon the need for ongoing care/complications associated with the condition.
  • What is the cause of the kidney disease? – There are multiple causes of kidney disease.  When known, the causative factor should be identified, documented and coded.
  • What is the stage of kidney disease? – The higher the stage of kidney disease the more care the patient is likely to need.  When the stage of CKD is not documented, it is coded as unspecified, which is not be associated with a risk factor score.
  • Does the patient require dialysis or transplant?

Diagnosing Chronic Kidney Disease (CKD)

CKD is a slow developing condition. The diagnosis of CKD cannot be coded from diagnostic studies alone. A review of a patient’s diagnostic studies, pertinent clinical findings and the stage of CKD must be documented in order for a diagnosis of CKD to be coded.  The following table will help you determine the stage/severity of a patient’s chronic kidney disease.

Stage Severity GFR ICD-10 code
Stage I Normal or slightly increased GFR GFR > 90 ml/min   with   kidney damage* N18.1
Stage II Mild kidney disease GFR 60-89 ml/min   with   kidney damage* N18.2
Stage III Moderate kidney disease GFR 30-59 ml/min N18.3
Stage IV Severe kidney disease GFR 15-29 ml/min N18.4
Stage V Stage 5 - Kidney Failure GFR < 15 ml/min N18.5
End Stage Renal Disease

End Stage Renal Disease Requiring chronic dialysis or transplant N18.6
Unspecified CKD CKD NOS, Chronic Renal Failure or Chronic Renal Insufficiency Chronic Kidney Disease Unspecified N18.9

*Patients with stage 1 or 2 kidney disease (based on results of GFR) require additional evidence of kidney damage (protein in the urine for 3 months or more, ultrasound or biopsy evidence of kidney disease) before a diagnosis of CKD can be made. 

Documentation that Supports Chronic Kidney Disease

In order to support a diagnosis of CKD, documentation must indicate that the patient has chronic kidney disease and include at least one of the following:

  • Review of diagnostic reports (blood, urine, imaging)
  • Pertinent clinical findings
  • Stage of CKD
  • Management of CKD

Additional documentation that assists in accurate coding of CKD includes any of the following that apply:

  • Patient has an arterial venous shunt
  • Patient is on renal dialysis
    • Hemodialysis
    • Peritoneal dialysis
    • Patient is non-compliant with dialysis
    • Patient had a transplant
    • Patient had post-transplant complications (include what the complication is)
    • Complications related to CKD and its management

Chronic Kidney Disease and Secondary Conditions

Documentation related to kidney disease should include any additional or secondary conditions that may be present.  Clearly state any causative relationship that exists between the conditions.

Hypertension

ICD 10 coding guidelines assume a cause and effect relationship between CKD and hypertension when a patient has both conditions.  When present together, both conditions should be documented, diagnosed and coded.

End Stage Renal Disease (ESRD)

ESRD is a condition of stage V CKD that requires chronic dialysis or transplantation.

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598

Ann Meverden
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9352

Shared email:   rf.shp.risk.adjustmnt@securityhealth.org